| A trigger tool fails to identify serious errors and adverse events in pediatric otolaryngology. | |
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MedLine Citation:
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PMID: 20869555 Owner: NLM Status: MEDLINE |
Abstract/OtherAbstract:
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OBJECTIVE: To identify and quantify errors and adverse events on an inpatient academic tertiary-care pediatric otolaryngology service, a trigger tool was developed and validated as part of a quality improvement initiative. STUDY DESIGN: Retrospective record review. SETTING: Children's Hospital Boston quality improvement initiative. SUBJECTS AND METHODS: Fifty inpatient admissions were reviewed. The gold standard for errors and adverse events identification was a detailed chart review by two board-certified otolaryngologists blinded to trigger tool findings. RESULTS: Trigger tool interrater reliability ranged from poor to high for admission triggers (kappa = 0.35, 95% confidence interval [95% CI] -0.07 to 0.76), discharge triggers (kappa = 0.63, 95% CI 0.27-0.99), medical records triggers (kappa = 0.61, 95% CI 0.11-1.00), and medication triggers (kappa = 0.90, 95% CI 0.71-1.00). Errors and adverse events were found in all admissions: three percent were potentially harmful, and 93 percent were documentation-related. CONCLUSION: The trigger tool was successful in identifying clerical and administrative errors and adverse events but failed to identify complex errors and adverse events. A hybrid approach for chart review may be cost-effective in pediatric otolaryngology. |
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Authors:
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Lina Lander; David W Roberson; Katrina M Plummer; Peter W Forbes; Gerald B Healy; Rahul K Shah |
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Publication Detail:
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Type: Journal Article; Research Support, Non-U.S. Gov't; Validation Studies |
Journal Detail:
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Title: Otolaryngology--head and neck surgery : official journal of American Academy of Otolaryngology-Head and Neck Surgery Volume: 143 ISSN: 1097-6817 ISO Abbreviation: Otolaryngol Head Neck Surg Publication Date: 2010 Oct |
Date Detail:
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Created Date: 2010-09-27 Completed Date: 2010-11-12 Revised Date: - |
Medline Journal Info:
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Nlm Unique ID: 8508176 Medline TA: Otolaryngol Head Neck Surg Country: United States |
Other Details:
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Languages: eng Pagination: 480-6 Citation Subset: IM |
Copyright Information:
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Copyright © 2010 American Academy of Otolaryngology–Head and Neck Surgery Foundation. Published by Mosby, Inc. All rights reserved. |
Affiliation:
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Department of Epidemiology, College of Public Health, University of Nebraska Medical Center, Omaha, NE, USA. llander@unmc.edu |
Export Citation:
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| MeSH Terms | |
Descriptor/Qualifier:
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Child Humans Medical Errors* Medical Records Medication Errors Observer Variation Otolaryngology Otorhinolaryngologic Surgical Procedures* Patient Admission Patient Discharge Risk Factors |
From MEDLINE®/PubMed®, a database of the U.S. National Library of Medicine
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